I read with interest the recent article on drug safety, especially noting Dr. Larson's advice—which reminded me of similar advice I received during training—to select a few drugs in each class and "know them well." ("Drug-safety issues spur debate over monitoring," March ACP Observer.)
Unfortunately, in the managed care world of tiered pharmacy benefits, such an approach is simply untenable. Health plans can select different "preferred" drugs and change the list far too frequently. To meet patient needs and expectations, physicians must be prepared to prescribe virtually any medication.
Unfortunately, if doctors receive capitated payments from a health plan, that plan's demand for cost savings on pharmaceuticals actually results in additional expense for the physicians. That's because doctors will have to set up additional office visits to change and adjust medications, and set up new plans for monitoring effects. Even for physicians paid on a fee-for-service basis, gathering information about the enormous number of equivalent drugs represents another form of cost-shifting to doctors.
Today's environment of inexorable demands for lower physician fees is unsustainable. Requiring additional physician work only makes things worse.
Richard S. Frankenstein, FACP
Garden Grove, Calif.
As a physician, I find it upsetting to hear my colleagues and I referred to as " providers." ("TRICARE: Is the military program turning around?," March ACP Observer.)
The current habit of referring to all health care professionals—physicians, nurse practitioners, midwives or military medics—as "providers" only serves third-party and government payers by artificially leveling our respective educational and clinical playing fields. As long as we all are simply "providers" rendering a "service," physicians' clinical expertise can be negated and our reimbursement reduced.
By the same token, trying to codify diagnoses with ICD-9s falls far short of capturing the diversity of how disease manifests in different patients. Like the use of the word "provider," codifying diagnoses was done to help nonmedical personnel understand and simplify medicine, making it easier for them to categorize "care" and dictate reimbursement.
Physicians should stop acquiescing to attempts to make medicine something it's not. We need to re-educate the public to view wellness and disease with the awe and respect they deserve—and insist on being called "physicians," a term that distinguishes us as highly trained professionals who work to safeguard the quality and quantity of life.
Coleen Madigan, FACP
Corpus Christi, Texas
I read with interest your recent article on detecting sleep disorders. ("How to detect common sleep disorders," March ACP Observer.)
I would like to add nocturnal reflux to the causes of sleep disorders, which may affect up to 60% of patients with this disease. Between 7% and 14% of the U.S. population is reported to suffer from heartburn on a daily or weekly basis, and heartburn is a cardinal symptom of reflux disease. Of these patients, over 70% are believed to have nocturnal symptoms. This translates into a significant percentage of people affected by sleep disturbances due to gastroesophageal reflux disease.
Based on a recent survey by the American Gastroenterological Association and Gallup Organization, nighttime heartburn seems to be an underappreciated clinical problem that impacts sleep and daytime function.
Reza Shaker, FACP
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